A Nation Of Nonreaders

Nearly half of all adults in America cannot read or comprehend material if it is written at or above the eighth grade level. Many of these functional illiterates and marginal literates are our patients. Some of them are our coworkers. However, the true scope of this problem stays hidden because people who do not read well are very good at masking their poor reading skills.

I first noticed this serious problem when I was 19 years old and working at a grocery store.

One of my coworkers, a middle-aged mother of three who had been married for 15 years, asked for my assistance with reading and properly completing a time-off request form. "I am not good at writing things," she chimed with a smile on her face. She added, "I forgot my glasses, so I can't see this paper too well today."

While helping her with the form, which was written at a fifth or sixth grade level, I made some silent observations. First of all, this woman was a high school graduate. Moreover, I never saw her wearing eyeglasses during the entire year that I worked with her. Her excuses of being a bad writer and forgetting her glasses were likely intended to mask an awful truth.

My coworker did not know how to read very well.

When I started working as a nurse, I suspected that some of my coworkers lacked basic literacy skills. For instance, a middle-aged nursing assistant with whom I once worked started crying one afternoon several years ago after staring at a letter that had been given to her by the human resources manager. The assistant asked, "What is this paper? Are they going to fire me?"

After glancing at the letter, I determined within a few seconds that it was the same preprinted memo that every employee in the facility had received regarding yearly open enrollment for health insurance. I reassured her and gently told her about the letter's contents, and she thanked me. I also surmised that this woman would have never cried over the memo in the first place if she was comfortable reading the written word.

Many people do not read very well. According to the 2003 National Assessment of Adult Literacy, 63 million adults in the U.S. do not read proficiently enough to comprehend an article written at the eighth grade level and another 30 million people read at or below a fifth grade level. In other words, a whopping 93 million people possess low levels of literacy. This is almost half of all adults in America! However, the true scope of this problem lurks in the shadows because functional illiterates and marginal literates are usually very astute at covering up their poor reading skills.

It's a sad fact of life that many of our patients and some of our coworkers do not read well. For example, a patient who delays signing consent paperwork because he's tired or forgot his glasses (even though he denied wearing eyeglasses during the initial assessment) might be an illiterate. The CNA at the nursing home who procrastinates when asked to write a statement regarding a fall and always requests help from others to complete her flow sheets might be a nonreader. Since many people who do not read are well-dressed, articulate and work in respectable occupations, it is a problem that cannot be detected by simply looking at a person or studying one's demographic information. In addition, people with poor reading skills have spent much of their lives learning creative ways to hide their inadequacies from others.

Low literacy skills can negatively affect patient outcomes. First of all, the marginally literate patient might cheerfully nod, pretend to understand, and simply sign written discharge instructions when he did not comprehend the paperwork. In one case, a patient was given full-sized 8x11 inch papers that were light blue in color and did not realize that these were prescriptions because he could not read them well enough. Some patients are readmitted for the same chronic illnesses repeatedly. While noncompliance might be a major part of these readmissions, one must wonder if these people really understand what we're telling them.

There are no simple solutions to this complex problem. However, nurses can help in small ways by providing clear verbal discharge instructions and taking great care to avoid medical jargon. The nurse should check for understanding by requesting that the patient repeat the instructions in his own words and watch as the patient demonstrates any hands-on skills that he was taught by staff. Patients who are marginally literate can read and comprehend pamphlets if they are written at a sixth grade level.

If you suspect that a subordinate coworker who reports to you is unable to read well, use simple verbal directives, keep explanations short, and ask the person to restate the directions in his/her own words to ensure comprehension. Do not confront the coworker on the alleged inability to read or do anything to embarrass him/her.

There are also nurses (some in high places) with poor literacy skills. I am amazed at how many of my RN co-workers have trouble reading anything written at the college level. They struggle to understand the nursing literature and can only scratch the surface of understanding a research article or self-paced educational module.

Sometimes, I am not sure how much of the problem is their true lack of ability ... and how much is just intellectual laziness. They don't seem willing to invest the time and effort necessary to read more than a few words or phrases. For example, I recently sent an e-mail of about 4 sentences telling someone where and when I would meet with her. Her response? "3:30 is great. Where?" That type of response happens all the time. Didn't she read the entire message?

I have students in class who don't read the syllabus -- and therefore don't hand in their work on time, or follow the directions provided in the assignment. It's as if the only read their text messages and won't/can't read anything longer than a tweet.

There are also nurses (some in high places) with poor literacy skills.

Yes. Some of the email communications and memos that I receive from nurse managers and chief nursing officers leave me puzzled. The grammatical errors, poor punctuation, bizarre phraseology, and numerous misspellings (not typos) seem so unbecoming of people who have been educated at the graduate degree level.

It makes me wonder how these people skirted through college-level English courses and managed to receive passing grades.

However, studies have indicated that literacy levels in today's college-educated populace are dropping as the years pass. Just some food for thought...

Dec 4, '12

Perfect article is perfect.

This is an issue that every nurse needs to be well aware of. (<== ugh. Grammar.)

Digress. I have been part of surgeries that have canceled because the patient truly did not understand what was going to take place. All of the literature they were given pre-operatively by various physician's offices, etc was not clear to them.

This plays a huge part in discharge teaching, home medication use and potential for repeat hospitalization. It is heart breaking some of the devastating effects decreased literacy can have.

On a separate note, many of these folks are so clever and have managed for so long that if you weren't looking for it, just like with your co-worker, you would never know.

Nicely done.

Cheers,

~~CP~~

Dec 4, '12

As a mom of a pre-K student, I'm troubled by the standards of our public school districts. Because of this, I intend on homeschooling my child. Due to texting and chatspeak, as a nation our spelling skills are falling off the map. I'm afraid as more assignments are done on computer, the art of handwriting is going to be lost. Already the local school districts are dropping cursive writing; you can bet I will teach cursive to my daughter. It's so sad that the US standards in so many vital areas are dropping so fast.

Dec 4, '12

Thank you for this article. I feel like a light bulb just went off in my head. I have an aide at my LTC facility that seems to do about anything to avoid doing her coomputerized ADL charting or her inservices (also computerized). She is an older lady and honestly one of the best aides I have ever worked with. She says she hates the computer (she's late 50's so doubt she has much experience with computers) but now you've got me wondering if there is really a literacy issue at play.

Dec 4, '12

I knew a nurse who was severely dyslexic, that his spelling was terrible and reading his triage narratives were a nightmare. Sometimes funny, but often difficult to understand what the patient presented to the ED for. He had a real issue. Other nurses, when they make spelling mistakes in their notes are just plain lazy, and I've seen that too.

Dec 4, '12

I'm blessed to be the father to two great kids, ages 8 and 14. My son LOVES to read. I still recall my sense of amazement when seeing him laying on the floor, sounding out words. He is also getting better at controlling his voracious appetite for reading while in school. His teachers aren't having to keep him from reading books for fun while in class, as had happened over the past 5 years or so.

My daughter, 8 years old, also loves to read.

I was recently told by my 20 year-old nephew that "books are dead." He said that there is no further need for printed books, since e-readers and tablet PCs are so common now.

I'm glad to see that my kids disagree. While they enjoy DVDs, a small amount of mindless TV, and playing on an iPad, they both still enjoy the written word. Both of them make good use of their library cards.

I guess it comes from belonging to a family with book-loving parents.

Dec 4, '12

I have younger, school-age cousins that would rather fail a class, than read for ten minutes. These are the same cousins that sit around playing video games, watching television, on the computer, or on the phone all day. I feel so bad because one of my younger brothers (in his twenties now) did the same thing when we were younger and now he struggles with spelling. Do they care? Absolutely not, because they've been able to get by for so long without anyone stressing the importance of reading. I read the dictionary and newspaper and practically fell in love with the public library as a kid. I am not "better than" anyone, but I really wish my younger cousins understood the benefits of reading.

I knew a nurse who was severely dyslexic, that his spelling was terrible and reading his triage narratives were a nightmare. Sometimes funny, but often difficult to understand what the patient presented to the ED for.

Poor spelling is not always an example of illiteracy. I know plenty of well read people who for whatever reason have poor recall when it comes to spelling.
The way children assimilate information in daily life is changing. When books first started being written people feared that our ability of memory would go away. The idea being that if everything is written down, you would no longer memorize or remember things.
It seems to me that, with the advent of all this technology, the educational system is failing to keep up with the differences between then and now. ( on a personal note, no child left behind has been implemented very poorly.)
I think we are in a transitional period. When Google can find an answer to virtually any question you may have, it becomes harder to find the applicability of school as I knew it. That's my two cents, rambling though it may be.

Dec 5, '12

Thanks for a great post/reminder. This stuff has serious implications for 1) Comprehension of material and 2) How knowledge is disseminated and interpreted. Communication is everything, particularly in regards to patient safety.

Not to pick on nurses, but do you think the type/style of reading and writing required for the job is a hindrance? So many check boxes, abbreviations, etc. makes it hard to construct much less understand writing with any flourish. I think of my friends with jobs/majors in other fields and I feel like a dummy next to them - they are so well read and write beautifully. I sometimes go back and re-read stuff I wrote in high school and liberal arts college classes and think, "Darn, that was pretty good. Did I really write that?" Don't think I could do it today...the agony/anxiety I'm experiencing over writing in grad school is evidence of the slow and steady decay of these "soft" skills...

Also, having to proofread the work of class mates is equally painful. We're all grad students, and yikes! Whole sentences/paragraphs that make. no. sense. It's really hard to give positive feedback to someone who has produced something that is essentially unreadable. The nicest way (that I've come up with so far) to give constructive criticism is to say "Always make sure you have someone proofread for you. It can be hard to catch your own mistakes."

Dec 5, '12

Just to play devil's advocate:

It's so sad that the US standards in so many vital areas are dropping so fast.

I have to wonder how much of that stuff is really "vital" anymore. Latin, short hand, and Morse Code used to be all the rage. Now they're "dead" languages. The day may come where cursive writing goes the way of the DoDo and why shouldn't it? The need for cursive was to 1) be faster and 2) prevent ink dripping all over from lifting the quill off the page. The age of ball point pens removed half that need, and word processors removed the other. Printing will do just fine.

Take it a little further and the age of computers, phones, etc. may remove the need for writing (ie. actual physical "writing") altogether, given enough time. There's not necessarily anything wrong with that, as long as humans are able to communicate effectively by pushing buttons and being able to interpret the output. *That is where the problem lies - the interpretation part. Standardization is a key component to any successful language - people have to agree on what things mean. Not being able to interpret the output, or create output that others can interpret is where we get into trouble. This is what we need to keep in mind when working with patients and colleagues: can they understand the communication, whether written, verbal, or physical demonstration.